ARCHETYPE Examination of both lips (openEHR-EHR-CLUSTER.exam_lips.v0)

ARCHETYPE ID

openEHR-EHR-CLUSTER.exam_lips.v0

Concept

Examination of both lips

Description

Findings observed during the physical examination of both lips.

Use

Use to record a narrative description of the overall findings observed during the physical examination of the lips. This initial draft archetype consists only of the core examination pattern data elements (as per CLUSTER.exam_pattern) and will likely be expanded further over time as specific clinical requirements are identified.
This archetype has been specifically designed to be used in the 'Examination findings' SLOT within the CLUSTER.exam_mouth archetype, but can also be used within the OBSERVATION.exam and other OBSERVATION or CLUSTER archetypes, where clinically appropriate.
Use to provide a framework in which other CLUSTER archetypes can be nested in the 'Examination findings' SLOT to record additional structured physical examination findings - for example, CLUSTER.exam_lip.
The CLUSTER.exclusion_exam archetype can be nested within the 'Examination not done' SLOT to optionally record explicit details about the examination not being performed.
Use to incorporate the narrative descriptions of clinical findings within existing or legacy clinical systems into an archetyped format, using the 'Clinical Description' data element.

Misuse

Not to be used for recording data not related to the physical examination of lips.
Not to be used for recording the clinical history - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom.
Not to be used to record stand-alone clinical observations or measurements or test results - use specific OBSERVATION archetypes. For example OBSERVATION.blood_pressure or OBSERVATION.imaging_exam.

Purpose

For recording a narrative description and clinical interpretation of the findings observed during the physical examination of the lips.